Provider Demographics
NPI:1083751192
Name:IVANCIC, SUSAN I (RN, BSN, CDE, SNIV)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:I
Last Name:IVANCIC
Suffix:
Gender:F
Credentials:RN, BSN, CDE, SNIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MONTECILLO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3308
Mailing Address - Country:US
Mailing Address - Phone:415-444-2575
Mailing Address - Fax:
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-2575
Practice Address - Fax:415-444-4622
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172329163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management